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Psychiatria Danubina, 2015; Vol. 27, Suppl. 1, pp 411–414
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Conference paper
PSYCHOGENIC SPEECH DISORDER – A CASE REPORT
Agnieszka Koźmin-Burzyńska1, Agnieszka Bratek1, Karolina Zawada2,
Krzysztof Krysta1 & Irena Krupka-Matuszczyk1
1
Department of Psychiatry and Psychotherapy, Medical University of Silesia, Katowice, Poland
2
Department of Pneumonology, Medical University of Silesia, Katowice, Poland
SUMMARY
Background: Conversion (dissociative) disorder is a psychiatric disorder in which somatic symptoms or deficits are present in
the absence of a definable organic cause. The etiology of this disorder is not yet fully understood. The most characteristic
presentations are: pseudosensory syndromes, pseudoseizures, psychogenic movement disorders and pseudoparalysis. Psychogenic
speech disorder is a rare form of conversion (dissociative) disorder. The aim of present case study is to complete the knowledge on
this subject.
Subject and methods: The article presents a case of a fifty year old woman who developed psychogenic disorder of speech after
being degraded to a lower position at work. After excluding organic background of observed symptoms, the diagnosis of conversion
(dissociative) disorder was stated and adequate therapy was implemented, within the capabilities of the Ward.
Results: Partial remission of presented symptoms was achieved as a result of psychopharmacotherapy and psychotherapy.
Conclusions: Before stating the diagnosis of conversion (dissociative) disorder, possible somatic causes of the observed
symptoms should be excluded. Special attention should be drawn to the importance of studying the psychological and family context
of this case and the patient’s difficulty to understand and accept that produced symptoms might be triggered by a psychogenic factor.
Key words: conversion disorder – speech - psychotherapy
* * * * *
INTRODUCTION
The etiopathogenesis and the concept of dissociative/conversion disorder was being revised over the
years. The common feature of dissociative/ conversion
disorder is a partial or a complete loss of the normal
integration between the sense of identity, memories of
the past, sensory impression and control of voluntary
movements (American Psychiatric Association 2013;
World Health Organization 1992). Both diagnostic
classifications - ICD-10 and the classification of the
American Psychiatric Association – DSM, unequivocally require that the diagnosis of conversion /
dissociative disorder should be stated only after excluding active psychoactive substance use, neurological
disorders and disorders associated with somatic conditions. According to the newest, fifth edition of the
Diagnostic Statistical Manual (DSM-5) (American
Psychiatric Association 2013) dissociative disorders are
defined as a separate category, and conversion disorders
are included in the category of somatoform disorders. In
the ICD-10 the terms “conversion” and “dissociation”
are used interchangeably, but the latter one is used more
frequently. This is due to the suggested psychodynamic
etiology that is associated with the word “conversion” that is, the suppression of unacceptable desires and their
"conversion" into the somatic symptoms (World Health
Organization 1992). This also enables us to avoid
defining classified terms with the concepts emerging
from certain psychological theories (Isaac 2005). The
authors used the ICD-10 while describing the present
case. According to this classification, dissociative/con-
version disorders are characterized by the total or partial
loss of proper integration of memories of the past, the
sense of self-identity, sensory sensations and control of
body movements, combining, unlike the DSM-5,
impaired cognitive and motor functions. This category
includes only somatic dysfunctions that are normally
under conscious control and disorders characterized
with the loss of sensory perception. Disorders involving
pain and other complex somatic sensations associated
with the activity of autonomic nervous system are
classified as somatoform disorders (F45.0). According
to the DSM-5, the term "dissociation" is used for
disorders of consciousness and memory, while the term
"conversion" for motor and sensory impairments –
hence, dissociative disorders form a separate group,
while conversion disorders are included in the group of
somatoform disorders. According to the ICD-10, conversion (dissociative) disorders have a psychogenic
origin and are closely related in time with traumatic
events, unmanageable and intolerable situations, or with
disturbed relationships with the environment. The
symptoms often are a reflection of patients' ideas about
how a somatic disease is manifesting itself. In addition,
the loss of function is an expression of psychological
needs and conflicts (World Health Organization 1992).
Conversion (dissociative) disorders are often associated
with symptoms such as: pseudoseizures, visual disturbances - double vision, blindness, tunnel vision, impaired perception of external stimuli, vocal cord dysfunctions (aphonia, articulation disorders - metathesis,
paralalia), hearing impairment, psychogenic movement
disorders and pseudoparalysis and puerilism (Cottencin
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Agnieszka Koźmin-Burzyńska, Agnieszka Bratek, Karolina Zawada, Krzysztof Krysta & Irena Krupka-Matuszczyk:
PSYCHOGENIC SPEECH DISORDER – A CASE REPORT
Psychiatria Danubina, 2015; Vol. 27, Suppl. 1, pp 411-414
2014, Verhoeven 2005). Patients do not produce these
symptoms consciously and cannot control them, which
distinguishes conversion disorders from factitious disorders (Munchhausen syndrome). Differentiating conversion disorder from organic mental disorders is
particularly difficult and requires the additional diagnostic procedures to exclude organic causes. “Red
flags” that point to dissociative conversion disorder
include an interview of recurrent somatic complaints of
unexplained background, frequent diagnostic procedures with inconclusive results and time correlation
between the occurrence of symptoms and a traumatic
factor (rape, the loss of loved ones, disaster) (Feinstein
2011, Kanaan 2011). When choosing a method of
treatment for a patient with conversion disorder (range,
form or psychotherapeutic technique) particular attention should be paid to the nature of the disorder and the
patient's general condition.
CASE REPORT
A 50-year-old patient was admitted to the Closed
Ward of the Clinic of Psychiatry and Psychotherapy of
Silesian Medical University in Katowice in May 2014
with a diagnosis of mixed dissociative (conversion)
disorders (F44.7 according to the ICD-10). It was her
first psychiatric hospitalization. Since August 2012 she
had been treated in an outpatient mental health unit.
Objective findings on mental status examination included the following: full orientation; maintained eye contact and cooperative behavior, difficult verbal contact
due to speech disorders, depressed mood, tearfulness,
slightly reduced psychomotor drive. She denied suicidal
or homicidal ideations or psychotic symptoms. She
complained of severe anxiety during the day (with no
identified cause), problems with concentration, disturbed first and third phase of sleep. During the study, the
patient presented speech disorders: stuttering, nasal
speech, replace the consonants (g → d, k → t), she used
similar-sounding words denoting something else, she
used many diminutives, she modulated her voice and
body poses as seen in puerilism.
Family history
The patient was brought up in a full family as a
single child. She was born and grew up in a big city, in
an industrial district. When she was in the primary
school, she had to move with her parents to the
countryside due to their jobs. The patient identified it as
a particularly difficult experience - after returning to the
previous place of residence she has been experiencing
difficulties in adapting to the new environment and in
establishing relationships with peers, which lead her to
skipping classes in secret from her parents. The
possessive attitude of her parents also disrupted her
contacts with peers, as she was being made to spend all of
her free time on education and household responsibilities.
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She was often punished physically by her father on
her mother’s command, even for minor misbehavior.
The patient presented her mother as a raw, emotionally
frigid person, focused mainly on the patient’s results in
education, applying physical and mental violence to the
patient even in adulthood and constantly interfering in
her personal life and intimate relationships. She
described her father as indifferent to her problems,
subordinated to her mother’s decisions and abusing
alcohol to alleviate negative emotions arising from the
domestic situation. As a teenager, the patient made
several attempts to rebel through secret meetings with
friends and her first boyfriend, which ended quickly due
to the intervention of her mother. Being in her early
twenties, she married a man after a brief relationship
and got pregnant, which she now identifies as an
attempt to escape from her parents. Two years after they
decided to divorce, according to the patient due to her
husband’s emotional immaturity. In order to prove to
her mother that she can manage, the patient made a
successful attempt to bring up her daughter without any
support, at the same time working and constantly raising
her qualifications. The relationship with her mother has
changed to a more reserved one when the patient
happily married her second husband in 2005.
History of mental health problems
Patient’s mental health problems began in July 2012
after she was moved to a lower position at work in
connection with a long period of being on a sick leave
due to rehabilitation treatment of spinal osteoarthritis.
The patient has been working for nineteen years for an
insurance company, eight years of which in an executive position as a supervisor of ninety agents. While
being on a sick leave, she received a phone call from her
employer who informed her that she has been degraded
to a lower position. The patient reported that after that
conversation her speech became incomprehensible, but
she was unaware of that. She was also experiencing
generalized anxiety, tearfulness, hands sweating, and a
significant reduction of sleep quality. Three days after
this event, the patient was found unconscious at home
by her daughter and taken to the Department of Neurology. Predominant symptoms were headache, spine
ache, and slurred speech. Neurologopedic consultation
was performed, which described distinctive slowing of
speech due to the difficulty in pronouncing words, a
tendency to chant and/or clonic stuttering of variable
severity, impaired naming and repetition, and functional
phonation disorder. Further diagnostic tests included
head imaging (computed tomography, magnetic
resonance imaging), which showed no brain pathology,
electromyography (nerve conduction in the upper and
lower limbs within normal) and vascular Doppler
ultrasound of the neck (correct carotid and vertebral
flow). After eleven days in the Department of Neurology, the patient was discharged with a diagnosis of
Agnieszka Koźmin-Burzyńska, Agnieszka Bratek, Karolina Zawada, Krzysztof Krysta & Irena Krupka-Matuszczyk:
PSYCHOGENIC SPEECH DISORDER – A CASE REPORT
Psychiatria Danubina, 2015; Vol. 27, Suppl. 1, pp 411-414
somatoform disorder (F45.0) with a recommendation to
continue treatment at a mental health clinic. After
leaving the hospital in August 2012, she began
outpatient mental health treatment, where she was
diagnosed with mixed dissociative (conversion) disorders (F44.7). Psychopharmacotherapy was administered: 20 mg of fluoxetine per day and 1 mg of lorazepam in case of a panic attack. After the treatment the
patient reported no improvement. In February 2014
there was a worsening of anxiety symptoms with panic
attacks (F41.0) (it used to be her main ambulatory
diagnosis at that time) mainly in public transportation
and worsening of speech disorders which the patient
associated with the death of her mother-in-law and
being called as a witness in the case of on one of her
subordinate insurance agents. Then, due to the severe
breathlessness, bronchodilators were administered. In
addition, she was experiencing anxiety in the morning
and in the evening, agoraphobia and the fear of being in
the house alone. According to the patient's daughter,
before the symptoms started she was an energetic and
feisty person, the change which took place was so
radical that the daughter decided to give up her own
veterinary practice to take care of her mother. The
patient was hardly ever leaving the house, she neglected
self-care and was spending most of the time in bed,
paresis of the lower limbs occurred.
The course of hospitalization
During the hospitalization on the Closed Ward,
neuroimaging and neurological consultation were performed, which excluded organic background of presented symptoms. Psychological examination was performed (Minnesota Multiphasic Personality Inventory
(MMPI), Structured Clinical Interview for DSM-IV
Axis II Disorder (SCID-II) and an interview with a
psychologist). The description of psychological examination indicated a conversion reaction under severe
stress, as the symptoms were causally related to the
traumatic event (being moved to a lover position at
work and subsequent impairment of speech the next day
with an occurrence of infantile features in her behavior).
In relation to superiors the patient functioned as a child
and was trying to "earn love and praise." Cognitive
functions tests did not indicate any impairments. The
patient showed features of histrionic and dependent
personality style, but she did not meet the criteria for
personality disorders. The patient was consulted by a
speech and language pathologist, who described presented speech abnormalities as logoneurosis. Compared to
the state described two years before at the Neurology
Department, cluttering was predominant, stuttering remitted, speech became more fluent and speech rate was
significantly accelerated. The articulation of individual
sounds, syllables, words, sentences still contained
numerous extensions and inclusions of sounds, inversions, anticipations, perseverations and palatalizations.
In stressful situations the above-mentioned speech
abnormalities escalated and verbal communication was
becoming much more difficult. During the stay,
lorazepam was gradually discontinued (initial dose was
2 mg per day). The patient was discharged in June 2014
in stable condition (anxiety level decreased, the patient
claimed better concentration, no problems with falling
asleep and less frequent waking during the night) with a
recommendation to undertake individual or group
psychotherapy.
The continuation of treatment started in July 2014.
During the hospitalization, the patient was focused
mainly on somatic symptoms, such as back pain,
headache and mild vertigo. The patient presented no
problems in relationships with other patients and
actively took part in therapeutic activities (psychodynamic group psychotherapy, music therapy, art
therapy, psychoeducation with elements of psychodrama regarding neurotic disorders, relaxation mainly autogenous techniques), although therapists
noticed that the patient was reluctant to work on her
own problems during the group meetings – she was
more eager to discuss other patients' issues. When she
was being motivated to undertake the work on her own
problems, she presented worsening of the speech
disorders symptoms, which was especially noticeable
when the patient presented her life history. During
individual talks with the therapist, the patient worked on
the explanation and her better understanding of psychological mechanisms of forming and meaning of her
symptoms. Over the course of the therapy the patient
obtained a partial insight into the psychological background of her symptoms. She was discharged home in
August 2014 in stable psychosomatic condition, speech
impairments became slightly less severe and frequent
that on admission. According to the patient and confirmed by the staff, also the symptoms of anxiety and
sleep disorders resolved themselves. During the second
hospitalization the patient was not receiving any
psychiatric medications. The patient was recommended to continue individual psychotherapy in an outpatient setting.
DISCUSSION
In the present case, the negative patterns of family
relationships – emotionally cold, strict, mother, who
was violating boundaries and father addicted to alcohol,
indifferent to the domestic situation – which at the same
time provoked the patient to revolt and to strive for
acceptance by her mother. During the hospitalization, it
was noticed that she functioned as a child towards the
superior and was trying to "earn the love and praise",
which manifested itself in being overly nice and polite
and frequently apologizing for her behavior. The patient
felt that her mother created an emotional distance and
coldness, blocking tenderness and closeness. Losing her
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Agnieszka Koźmin-Burzyńska, Agnieszka Bratek, Karolina Zawada, Krzysztof Krysta & Irena Krupka-Matuszczyk:
PSYCHOGENIC SPEECH DISORDER – A CASE REPORT
Psychiatria Danubina, 2015; Vol. 27, Suppl. 1, pp 411-414
position at work (90 subordinates, 19 years of work),
while her co-workers appreciated, respected and liked
her – can be interpreted as a loss of a mother figure and
a collapse of the existing mechanisms of functioning,
which could be a cause of regression and conversion
reaction. The occurrence of speech disorders may also
suggest problems with expressing anger verbally – she
was given no opportunity to disagree ("right to speak")
with her parents, she also lost it after being degraded at
work. The lack of complete remission of speech
disorders in our patient may result from the difficulty in
understanding and accepting the psychogenic background of the symptoms produced and confirms the fact
that the treatment of conversion disorder requires longterm psychotherapy. Existing literature on conversion
disorders of speech is limited (Nazarov 2015), therefore
this case is aims to complete the knowledge of various
forms of conversion disorder.
Acknowledgements: None.
Conflict of interest: None to declare.
References
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2. Cottencin OF: Conversion disorders: psychiatric and psychotherapeutic aspects. Neurophysiol Clin 2014; 44:405-410.
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4. Isaac M & Chand PK: Dissociative and conversion disorders: defining boundaries. Curr Opin Psychiatry 2006;
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5. Kanaan RA, Armstrong D, Wessely SC: Neurologists’
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Correspondence:
Agnieszka Koźmin-Burzyńska, MD
Department of Psychiatry and Psychotherapy
Independent Public Clinical Hospital No. 7 of Silesian Medical University
Ziołowa 45-47, Katowice, Poland
E-mail: [email protected]
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